Allegheny Health Network has set patient access strategies for hospitals and primary care.
Allegheny Health Network is pursuing a multipronged strategy to maintain patient access during the coronavirus disease 2019 (COVID-19) pandemic, the health system's president and CEO says.
In hotspot states such as New York, the COVID-19 pandemic has severely strained hospital and primary care capacity. Many other states such as Michigan, New Jersey, and Louisiana also are facing daunting capacity challenges. The United States leads the world in reported COVID-19 cases at more than 468,000 as of April 10, according to worldometer.
HealthLeaders recently talked with AHN President and CEO Cynthia Hundorfean to see how the Pittsburgh-based health system is managing patient access as the number of COVID-19 cases rise in Pennsylvania. Before joining AHN, she was chief administrative officer at Cleveland Clinic. Hundorfean earned her executive master of business administration degree from Weatherhead School of Management at Case Western Reserve University in Cleveland.
The following is a lightly edited transcript of HealthLeaders' conversation with Hundorfean.
HealthLeaders:What are the biggest hospital and primary care access challenges that AHN is facing in the COVID-19 pandemic?
Hundorfean: On the hospital side, the biggest challenge is preparing for a surge with an unknown timeframe and severity. We continue our planning efforts around supplies, personal protective equipment, beds, and staffing. Challenges around testing supplies continue.
On the primary care side, we do not have or anticipate access challenges. We have converted nearly 80% of our primary care visits to virtual (video, telephonic or e-visits) so that sick patients are able to be seen safely.
HL: How are you planning to triage hospital and primary care access if you experience a COVID-19 patient surge?
Hundorfean: We are working to ensure that we have as many beds available as possible. This means opening all licensed beds, converting existing sites of care—such as ambulatory surgery centers, and working with local leaders to secure locations for alternative hospital sites.
From a primary care perspective, we are able to temporarily and safely defer some chronic and well care to open up access for acute care needs. We also have initiated 24/7 on-demand virtual visits for acute care.
HL:How are you managing hospital access for COVID-19 patients?
Hundorfean: We are following Centers for Disease Control and Prevention guidelines with regard to our screening and treatment protocols of confirmed or suspected COVID-19 patients to minimize the risk of transmission and protect the health of our caregivers and other patients in the facilities. Caregivers are equipped with the recommended personal protective equipment, patients are in isolation rooms, visitation is prohibited, and enhanced cleaning protocols of clinical spaces have been implemented.
HL: How are you managing hospital access for non-COVID-19 patients?
Hundorfean: We have followed CDC guidelines and postponed all non-emergent surgeries. We have also postponed most wellness visits or moved these to a virtual setting. Ensuring the safety of non-COVID-19 patients in our hospitals is a top priority. We are utilizing negative pressure rooms for those patients who are COVID-19 positive or suspected positive, and we continue to follow strict protocols to avoid cross contamination.
With the coronavirus pandemic creating shortages of critical care staff and ventilators, anesthesiology resources can fill the gaps.
Operating room anesthesiologists and their equipment are well-suited to help treat coronavirus disease 2019 (COVID-19) patients, an anesthesiology expert says.
In COVID-19 hotspots such as New York City, there are shortages of critical care personnel and ventilators to treat severely ill coronavirus patients, and these shortages are expected to spread nationwide. To help address these shortages, OR anesthesiologists and their anesthesia gas machines, which include a ventilator function, are being shifted to ICU settings.
"People are now seeing that anesthesiologists are critical care medicine physicians. We deal with patients in the OR, and now we are happy to help in the ICU to manage patients," says Mary Dale Peterson, MD, president of the American Society of Anesthesiologists (ASA), and executive vice president and chief operating officer of Corpus Christi, Texas-based Driscoll Health System.
She says OR anesthesiologists have the training and experience to transition to ICU care. All anesthesiologists get a minimum of four months of concentrated work in intensive care units during a residency, and many other anesthesiologists also complete a fellowship year in critical care medicine and become board-certified in critical care medicine, Peterson says.
"It's common in large medical systems or smaller organizations where the anesthesiologists may have the most experience in critical care medicine. Every day, we deal with patients coming to us from critical care units or patients who are transitioning after major operations to critical care. Essentially, we provide bedside critical care while patients are in the OR getting major operations done," she says.
For anesthesiologists who have not practiced for several years or had their critical care training many years ago, the ASA and partner organizations have developed training resources to get them prepared for working in the ICU setting, Peterson says.
ASA, the Society of Critical Care Medicine, the Anesthesia Patient Safety Foundation, and the Society of Critical Care Anesthesiologists put together a specialized training just for anesthesiologists going back into the ICUs. It is basically a quick refresher course on managing patients in an ICU, she says.
Anesthesiologists can play several critical care roles to help treat COVID-19 patients, Peterson says.
"Hospitals have taken their anesthesia resources and used them in different ways. Some are deploying anesthesiologists full time to ICUs to take care of patients alongside their critical care medicine colleagues. Others are creating teams of anesthesiologists to relieve the burden of doing some procedures on COVID-19 patients such as intubation and putting in special monitoring lines."
Converting anesthesia gas machines to ICU ventilators
The ASA and the Anesthesia Patient Safety Foundation have established guidelines for redeploying anesthesia gas machines as ventilators in ICUs.
Primary considerations for converting anesthesia gas machines to ICU ventilators include installing extra filters to prevent contaminating the machines with coronavirus and setting humidification properly to ensure COVID-19 patients are not receiving too much dry air in their lungs, Peterson says.
Anesthesia gas machines also have advanced capabilities that are beneficial under coronavirus pandemic conditions such as vaporizers for delivering anesthetics that are in liquid form, she says. "For the most part, we do not need that in the ICU; but some ICUs are running out of sedative drugs, so we can deliver very low doses of our general anesthetic to keep patients sedated while they are on breathing machines."
At least initially, it is recommended to have OR anesthesiologists set up and monitor anesthesia gas machines that have been redeployed for ICU use, Peterson says. "They are different from ICU ventilators. We want the personnel who are most familiar with these machines to be the ones doing the conversion."
The first step is admitting your organization has a problem, says VCU Health's chief quality and safety officer.
Since 2016, VCU Health has launched more than four dozen workplace violence initiatives.
Healthcare organizations carry a heavy workplace violence burden, with about three-quarters of U.S. workplace assaults occurring in healthcare settings, according to the Occupational Safety and Health Administration. Workplace violence is prevalent in emergency departments—78% of emergency physicians have reported being targets of workplace violence in the prior 12 months.
"There is not one single silver bullet that makes your environment safer," says Robin Hemphill, MD, chief quality and safety officer at VCU Health.
Over the past five years, Hemphill says the Richmond, Virginia–based health system has taken several essential steps to address workplace violence: realizing that the organization had a problem, forming a committee to illustrate that the problem was systemwide rather than local, promotion of incident reporting, and letting the staff know that abuse is not part of their job.
"A lot of this is selling initiatives to your senior leadership and having them turnaround to become your biggest advocates," Hemphill says.
The initiatives are focused mainly on violent patients but also include measures to address staff-on-staff violence. Data shows the efforts are making a difference:
Using its electronic medical record, VCU Health flags patients who are at risk of violence, and VCU Police and security staff round on those inpatients. In January, VCU Police and security staff conducted 1,300 checks on potentially violent patients.
From fiscal year 2012 to FY2015, 15%–32% of VCU Health assault cases resulted in the employee missing time from work. In the current fiscal year, which concludes in June, 1%–2% of assault cases have resulted in the employee missing time from work.
In summer 2016, VCU Medical Center launched the Behavioral Emergency Rapid Response Team (BERRT) to address inpatients with urgent behavioral health needs and to help reduce workplace violence. In BERRT's first year, police assault charges at the medical center dropped more than 60%.
Comprehensive approach
Over the past five years, VCU Health has launched more than 50 workplace violence-related initiatives, which include the following:
BERRT: The BERRT program is modeled after VCU Medical Center's medical response team, which responds to medical crises at the bedside. BERRT features psychiatric nurses who are mainly deployed in two scenarios. First, the psychiatric nurses round on patients who have been flagged as potentially violent to see whether there are any additional needs related to patient care plans. Second, BERRT team members respond to in-the-moment situations where a care provider sees a potentially dangerous situation.
"The BERRT team comes to the bedside and helps the care team members to make sure everyone involved is safe," says Trina Trimmer, RNC-MNN, MSN, nursing safety operations and resources director at VCU Health.
Violence Prevention Committee: This panel meets monthly and has about 50 members. Several departments and stakeholders are represented on the committee, including executive leadership, legal, nursing, occupational injury, physicians, psychiatry, risk management, and VCU Police.
Emergency department security rounding: Patients are flagged in the electronic medical record at three levels, with Level 1 patients at the least risk of violence and Level 3 patients at the highest risk. When Level 3 patients present at the emergency department, VCU Police and security are notified and round on the patients.
Emergency department metal detectors: Installation of ER metal detectors not only addressed a potential threat but also sent a clear message to patients, visitors, and staff members, says Lisa Davis, MEd, RN-BC, nurse manager for VCU Health's Psychiatric Nursing Consultation Service. "When we put the metal detectors in the ED, that was huge. It was very visible and showed that we wanted to take care of people," she says.
Reporting: In 2018, VCU Health implemented electronic reporting for workplace violence incidents with the launch of the Post Assault Huddle Form. The form gathers data on violent incidents and engages staff members to identify strategies to reduce future risk.
The filing of a Post Assault Huddle Form triggers electronic notifications, says C. Taylor Greene, occupational injury prevention and safety manager at VCU Health.
"One sends a PDF file of the Post Assault Huddle Form to the key stakeholders, including the VCU Police, our chief nursing officer, and the supervisor of the victim. There's also a notification that goes out to the claimant of the form that thanks them for submitting the report and lets them know what is being done," he says.
Reporting of violent incidents is not mandatory, but it is "strongly encouraged," Hemphill says. "Reporting is not supposed to be a shackle, where you get abused by somebody then get in trouble for not reporting it. We want people to give us this information, but we don't want a punitive response for failure to report," she says.
Signage: VCU Health approved the deployment of zero-tolerance violence prevention signs last fall, Greene says. "The introduction of those signs started at 14 of the primary entrances of our inpatient facilities. We did an additional rollout of a slightly different version of the signs at our 45-plus ambulatory locations," he says.
Visitor identification: In February, VCU Health rolled out visitor badging on a trial basis, Greene says. "It's very similar to what is utilized in school systems, where you come into a facility, drop an ID in a scanner, and get a sticker badge with your picture, the destination you are traveling to, and the time that you arrived. We are using self-expiring badges that say 'void' on them after 24 hours," he says.
Future initiative
An upcoming initiative will focus on peer support for staff members who have experienced workplace violence.
"Although we have seen great progress in the number of the initiatives we have launched and have seen an anticipated increase in reporting, our staff members are now asking for peer support," Trimmer says.
VCU Health wants to move beyond focusing on why patients were becoming violent and what could be done to flag them and introduce intervention resources such as BERRT, she says. "Now, we are hearing our staff members say they want help for the team member who was a victim. The staff wants to know what we are offering for victims. We have initiated a group to work on that issue and we have looked at other organizations to see what they have in place."
Strategies to manage of a surge of patients at hospitals during a pandemic include establishing a crisis command center and transforming infrastructure.
As coronavirus disease 2019 (COVID-19) patients are surging across the country, there are five strategies health systems and hospitals should implement, a new BDO report says.
New York is expected to experience the country's first peak of COVID-19 patients in the next week or two, followed closely by other hotspot states such as Louisiana, New Jersey, and Michigan. The surge of patients is straining hospital capacity, healthcare worker staffing, and supplies of personal protective equipment (PPE) and ventilators.
Deb Sheehan, managing director at the BDO Center for Healthcare Excellence & Innovation, told HealthLeaders that she is cautiously optimistic that U.S. health systems and hospitals will be able to manage the surge of COVID-19 patients.
"Managing challenges around the patient surge during this pandemic will require Herculean effort; but if our healthcare workers have shown anything over the last few months, it's that they are committed to the task. In New York State, as example, there is a significant difference between resource demand in New York City verses the upstate regions. As a result, healthcare providers in Upstate New York and from across the country, where demand is not as high, are now heading to New York City to help care for patients," she said.
The new BDO report features five strategies to cope with COVID-19 patient surges.
1. Establishing crisis command center and setting crisis manager roles
Create a situation room staffed with the health system or hospital's most senior operational leaders. The situation room should focus on the most significant short-term and long-term questions, make key decisions, and communicate regularly with the C-Suite and/or board of directors. Examples of questions the situation room should address include how the organization can help care continuum partners and whether emergency credentialing processes are in place to boost the healthcare workforce.
Create a war room staffed with multidisciplinary leaders from areas such as communications, finance, human resources, and supply chain. The war room staff helps the situation room find answers to questions.
Create a press room led by senior communications and public relations staff to disseminate situation room decisions to internal and external audiences.
Conduct a daily crisis command center huddle to help coordinate the efforts of the situation room, war room, and press room.
2. Transforming infrastructure
Find unused or underused local facilities that would be fit for testing stations, triage areas, and isolation rooms. Assess hospital units that can be converted into private rooms for COVID-19 patients.
Manage patient flow, "including separating the worried well patients from your worried symptomatic ones." For example, worried well patients should be directed away from hospitals to get guidance and at-risk patients such as the elderly should get care in quarantined areas.
Work with public sector and private sector organizations to find unused facilities in your community that are suitable for hospital beds.
3. Streamlining processes
Work with local primary care practices to set protocols for when it is appropriate to send patients with COVID-19 symptoms to a hospital.
Contact your post-acute care partners about providing care to elderly patients and patients with underlying health conditions after discharge for COVID-19 critical care. Help post-acute care partners to have capacity to take these patients and expedite discharge to home.
Assess the COVID-19 care activities such as diagnostic testing at local retail clinics and other outpatient sites. When appropriate, encourage patients to utilize these resources.
Manage inventory of PPE such as communicating with existing suppliers and contacting nontraditional suppliers such as construction businesses.
4. Addressing workforce impacts
Communicate clearly and effectively with frontline clinicians and other healthcare workers about important issues such as availability of PPE.
Manage communication channels such as designating modes of communication for sensitive information.
Adjust staffing with health and safety considerations such as moving administrative staff to evening shifts to lower exposure risks for the entire workforce. Consult with your staff about these changes, including the financial impact on workers.
Increase remote work in departments such as finance, human resources, and information technology.
Support staff with on-site services such as food and mental health counseling as well as provide supportive accommodations such as resting areas and shower facilities.
Increase cleaning of campus surfaces and promote hand washing.
Enlist local nursing and medical school students to perform functions such as patient communication, patient flow management, and care coordination.
Recruit retired physicians and nurses to help address healthcare worker shortages.
Assess available telehealth equipment and review modifications of Health Insurance Portability and Accountability Act rules for telemedicine during the pandemic.
Find opportunities for rapid adoption of telehealth capabilities such as video conferencing and bots that can help patients assess COVID-19 symptoms and answer basic coronavirus questions.
Assess the performance and cybersecurity capabilities of telehealth technology. Performance levels impact patient experience, and telehealth technology should be vetted for cybersecurity requirements.
Learn about temporary changes to the federal cost-sharing waiver, including the option to reduce or waive cost-sharing for telehealth services.
A healthcare consultancy anticipates a shortage of 7,900 critical care physicians nationwide when the coronavirus pandemic peaks.
The country is facing a "massive shortage" of critical care physicians, according to coronavirus pandemic modeling conducted by Array Advisors.
The United States leads the world in reported coronavirus disease 2019 (COVID-19) cases, with the total as of April 6 at more then 336,000, according to worldometer. A significant percentage of COVID-19 patients require mechanical ventilation in the ICU setting, which is expected to strain critical care resources including staff as coronavirus patients surge in the coming weeks.
ICU staffing shortages are an urgent concern, Neil Carpenter, strategic planning vice president at Conshohocken, Pennsylvania-based Array Advisors said in a prepared statement.
"While the public attention has been on beds and ventilators, we must not lose sight of the staff needed to serve the coming influx of patients. We need a national conversation about how to support and leverage our existing expertise, as well as how to contend with the coming surge of COVID-19 positive [healthcare] providers. In this fight, we need every provider to be well enough to work," he said.
Addressing intensivist shortages
Given the projected nationwide shortfall of critical care physicians, it likely will be impossible to shift intensivists from state to state to meet expected staffing demand, according to Array Advisors. The healthcare consultancy says there are six options for healthcare organizations and public health officials to cope with the shortage:
1. Retain intensivists who test positive for COVID-19 to treat ICU patients via telemedicine or, if personal protective equipment is available, treat ICU patients directly
2. Allow intensivists who have only completed one year of critical care fellowships to practice independently
3. Waive licensing regulations to increase existing international tele-ICU services and allow more international tele-ICU services
4. Enlist retired intensivists to provide direct patient care in ICUs
5. Combine artificial intelligence with advanced practice practitioners to expand the critical care workforce
6. Limit the allocation of critical care resources to patients with "extremely poor prognoses"
The Society of Critical Care Medicine has recommended that hospitals adopt a tiered staffing model in newly created ICUs to stretch the supply of critical care workers during the COVID-19 pandemic.
Critical care physician shortfall
Array Advisors' primary model for the anticipated critical care physician shortage pegs the shortfall at 7,900 doctors nationwide. The model is based on several assumptions, including a ratio of one intensivist for every 14 ICU patients during the day and the loss of 10% of critical care healthcare workers to coronavirus infection during the surge of COVID-19 patients.
The model projects there will be shortages of critical care physicians in every state except Maryland. New York leads the list of the Top 10 states that are expected to have intensivist shortages:
There are dire shortages of several kinds of coronavirus-related personal protective equipment across the country.
During the coronavirus pandemic, there are ways that healthcare organizations can reuse or extend the life of some personal protection equipment (PPE), an infection prevention expert says.
PPE is a crucial element of protecting healthcare workers from the virus that causes coronavirus disease 2019 (COVID-19). In China, Italy, and Spain, thousands of healthcare workers have been infected with the coronavirus. One-third of U.S. doctors are at high risk of serious illness from the coronavirus because they are over 60 years old, new research shows.
Last week, the Association of Professionals in Infection Control and Epidemiology (APIC) released national survey results that show severe PPE shortages at many U.S. healthcare facilities, including lack of respirators, surgical masks, face shields, and goggles. This week, HealthLeaders spoke with APIC President Connie Steed, MSN, RN, about how healthcare organizations can reuse or extend the life of PPE.
N95 respirator masks, face shields, goggles, and surgical masks
At this point in the U.S. COVID-19 pandemic, maintaining adequate supplies of N95 respirator masks is the primary PPE supply chain challenge, says Steed, who is director of infection prevention and control at Prisma Health-Upstate in South Carolina.
"Where most facilities are having trouble is with the N95; so, we are trying as much as possible to limit its use; and when it is used, we extend its life when it is acceptable," she says.
At Prisma Health, supplies of N95 respirators are being maximized through prioritization of use in the treatment of COVID-19 patients, Steed says. "It should be prioritized for aerosol generating procedures—that's when you have droplets during the intubation or extubation of a patient, for example. You can put people in surgical masks and face shields for other care."
Another option to conserve N95 respirators when treating COVID-19 patients is to use powered, air-purifying respirators (PAPRs), she says. "One of the things that some hospitals are doing is the use of the PAPR, which is a hood; and there has been discussion about the reuse of those hoods and using them instead of N95s. The PAPR's level of protection is the same or higher than the N95."
N95 respirators, face shields, and goggles are sturdy enough to reprocess after use with COVID-19 patients or patients suspected of coronavirus infection, Steed says.
Reprocessing requires a room designated for disinfection of PPE and other equipment. For N95 respirators, face shields, and goggles, she says two disinfection methods are currently being used across the country: hydrogen peroxide mist and/or ultraviolet light.
N95 respirators go through a four-step disinfection process, Steed says:
After use, the respirators are placed in a container
The respirators are carefully transported to the disinfection room
Inspectors make sure the respirators are intact and not visibly soiled
The respirators are suspended on "basically a clothesline," then they go through a disinfection process with either hydrogen peroxide mist or UV light, or both
Surgical masks can also be conserved, she says.
For example, Prisma Health started universal masking this week at its hospitals, which requires all employees to wear surgical masks except when they are eating, drinking, or working in a private room. When employees come to a hospital to start a shift, they are screened for fever and other COVID-19 symptoms; and if they screen negative, they are given a surgical mask and a bag, Steed says.
"When a healthcare provider gets ready to go into a room with a suspected or confirmed COVID-19 patient, they would take the regular mask off and put it in their bag. Then they put on an N95 mask, face shield, and other protective gear, go into the room, take care of the patient, come back out, doff safely, and clean their hands. Then they put their daily mask back on their face."
The Centers for Disease Control and Prevention has established guidance for maximizing the supply of N95 respirators.
Gloves and gowns
The options for conserving gloves and gowns in COVID-19 treatment are limited, with gloves only appropriate for single use, Steed says.
Plastic gowns also are single-use PPE in COVID-19 treatment, but some cloth gowns can be reused, she said. "There are some hospitals that use cloth gowns that have fluid repellency. If that's the case, they can be doffed and laundered through a routine process, then reused."
Retired clinicians, who are often at high risk because of age, can contribute to pandemic response in several ways that do not involve direct patient care.
The American Medical Association (AMA) is providing guidance to retired physicians who are willing to help during the coronavirus disease 2019 (COVID-19) pandemic.
There is widespread concern over the potential for healthcare worker shortages during surges of COVID-19 patients across the country in the weeks and months ahead. For example, New York Gov. Andrew Cuomo issued a plea this week to healthcare workers in other states to come to The Empire State to bolster hospital staffing.
"I am asking healthcare professionals across the country, if you do not have a healthcare crisis in your community, please come help us in New York now," Cuomo said.
In announcing the guidance to retired physicians, AMA President Patrice Harris, MD, MA, said in a prepared statement that there are several considerations for these doctors as they weigh returning to medical practice.
"As with all people in high-risk age groups, careful consideration must be given to the health and safety of retired physicians and their immediate family members, especially those with chronic medical conditions. The availability of personal protective equipment (PPE), and the opportunity to provide non-direct patient care are also special considerations," Harris said.
The AMA guidance to retired physicians features six factors they should consider.
1. Licensure: Retired physicians should check the licensing regulations in their state, the AMA guidance says.
"The licensure status of retired physicians varies by state. In some states retired physicians maintain their regular license while others create a separate category for retired or inactive physicians, and still others have no license category for retired physicians. In response to COVID-19, many states have taken action to allow retired physicians to temporarily return to practice through an executive order, department of health order, or board of medicine directive."
The path to re-entry is another licensure consideration, the AMA guidance says.
"For senior and retired physicians who maintain an active license, there are no licensure restrictions on re-entry to practice. For physicians who maintain an inactive, retired physician, or similar license, your state may have temporarily waived any barriers to re-entry. We encourage you to check the Federation of State Medical Boards' COVID-19 resource on state actions on license status for inactive/retired physicians for guidance."
Retired physicians should also consult with their state medical boards, the AMA guidance says.
2. Contributing effort: There are multiple ways for retired physicians to participate in COVID-19 pandemic response that do not include direct patient care, the AMA guidance says:
State health departments need volunteer clinicians and healthcare workers
Contact medical schools and offer to provide online teaching and mentoring for medical students
Donate blood
Social isolation is a challenge at nursing homes and senior residential communities—offer to provide online outreach
Help physician practices in your community to create patient education materials
3. Working at your former physician practice: "Explore opportunities to provide mentoring or training in your practice location. Many institutions have developed algorithms for telephone triage and/or assessment of symptomatic patients," the AMA guidance says.
4. Liability: There are several considerations for liability coverage, the AMA guidance says.
Check for coverage through your local health system
For licensed physicians who volunteer, the third federal economic COVID-19 stimulus package (H.R. 748), includes liability protections
Contact your state medical association to see whether you have liability protections under state law such as a recent gubernatorial executive order
5. Retirement income: "Some physicians are receiving retirement income that may be affected by a return to paid employment. Check the status of your retirement income according to the role you are being asked to perform," the AMA guidance says.
6. Clarify your role: If you will be working at a healthcare facility, ask questions about the role you will be playing such as the activities you will perform, provision of training or mentoring, and whether you will be given personal protective equipment.
As they confront the coronavirus pandemic, frontline healthcare workers are at risk for mental health conditions such as depression and anxiety.
During the coronavirus disease 2019 (COVID-19) pandemic, the mental health needs of healthcare workers should not be overlooked, a disaster response expert says.
Healthcare workers are in a precarious position on the frontlines of the struggle against COVID-19. In China, Italy, and Spain, thousands of healthcare workers have been infected with the coronavirus. Last week, more than 150 healthcare workers in four Boston hospitals were reported to have been infected.
HealthLeaders talked with disaster response expert Regardt "Reggie" Ferreira, PhD, to get his perspective on the mental health impact on healthcare workers during the pandemic. He is an associate professor at Tulane University School of Social Work, and program director of the Tulane University Disaster Resilience Leadership Academy in New Orleans.
Ferreira has been program director of the Disaster Resilience Leadership Academy for the past four years, and he has worked in the disaster response field since 2002.
The following is a lightly edited transcript of his discussion with HealthLeaders.
HealthLeaders: Do you have any overarching comments on supporting the mental health of healthcare workers during the COVID-19 pandemic?
Ferreira: The mental health aspect of a disaster oftentimes gets left behind. Especially for first responders and medical personnel, more attention should be given on this subject.
HL: For healthcare workers, what are the primary mental health concerns during the pandemic?
Ferreira: Medical professionals are likely to experience fear, anxiety, and a sense of powerlessness. There could even be aspects such as rage and anger toward the folks who have not followed the social distancing protocols.
There can also be compassion fatigue. Healthcare workers already had stressful jobs day-to-day. Adding the additional stresses from the COVID-19 pandemic—where there are so many unknowns—is going to be difficult on healthcare professionals. There is a lot of uncertainty about what is going to come at them and that can compound and filter into their home life. There is a range of emotions that is being felt at this stage of the pandemic.
HL: Are there emotional responses that could lead to a serious mental health crisis for healthcare workers?
Ferreira: For all of the things that I have mentioned, if they are not addressed, they can compound, and depression can set in and anxiety can set in. Over the long term, if healthcare workers are constantly operating under fear, they can make mistakes.
HL: What can healthcare workers do to avoid developing mental health problems during the pandemic?
Ferreira: Healthcare workers can focus on self-care, which can include reading, participating in self-help forums, keeping a diary, limiting social media exposure, talking to a friend or loved one about what they are experiencing, doing physical exercise, engaging in meditation and mindfulness, and switching off when they go home. These are all things that healthcare workers can do that are fairly easy to do if they are made a priority.
If healthcare workers are slipping into depression, they should be talking with a counselor or a therapist.
HL: What can health systems, hospitals, and physician practices do to support the mental health of healthcare workers during the pandemic?
Ferreira: At the top of the list is having clear communication with healthcare workers. They should be getting constant updates—this is a very fluid situation and there is new research coming out. There can be regular town halls with MDs, nurses, and other healthcare professionals.
Healthcare facilities should also be providing the necessary resources for providing care safely, which is difficult with shortages of materials and equipment.
Something tangible that can be of help is providing transportation to and from healthcare workers' places of residence; and if they are sequestered, healthcare facilities can provide housing. I spoke with a doctor in New York, and he said there are a lot of staff members who are afraid to go home because they have relatives who have diabetes, COPD, and other conditions, and they don't want to go home and infect family members.
Healthcare organizations can provide counseling and have support groups available—they can amplify the social support system at work. I'm sure there are many therapists at health systems who are willing to step up to the plate and help healthcare workers.
HL: From a mental health perspective, what aspects of this pandemic could be most challenging for healthcare workers?
Ferreira: The unknown. We fear the unknown, which creates stress. My advice is to take the situation day-by-day because it is so fluid. It's important not to look too far into the future. It's better to go day-by-day because if you try to look two or three months into the future, fear can lead to anxiety and depression.
If we have care rationing, there are going to be decisions that have to be made that are life-or-death decisions. Clinicians are going to be faced with those decisions—they are going to have to turn some patients away.
Doctors in Wuhan, China, share steps to establish temporary hospitals for coronavirus patients.
At the epicenter of the coronavirus disease 2019 (COVID-19) pandemic—Wuhan, China—health officials followed a five-step process to establish more than a dozen temporary hospitals in preexisting nonmedical buildings, a recent journal article says.
Over the past two weeks, China has had a relatively stable number of reported COVID-19 cases at more than 81,000, according to worldometer. in the United States as of March 31, there had been more than 164,000 confirmed cases, with more than 3,100 deaths, worldometer reported.
The recent journal article on temporary COVID-19 hospitals in Wuhan was published as part of a special article series in the journal Anesthesiology. The temporary hospitals played a key role in addressing the COVID-19 outbreak in Wuhan, the journal article says. "The establishment and operation of temporary COVID-19 specialty hospitals proved to be useful in the control of an infectious crisis within Wuhan, China, and will hopefully provide a blueprint for the management of future epidemiologic disasters."
The primary purpose of the temporary hospitals is to help control the COVID-19 outbreak in Wuhan by admitting all COVID-19 patients who are asymptomatic or exhibiting mild symptoms, the journal article says. "These temporary specialty hospitals can dramatically and immediately expand the admission capacities of the whole city, reduce the burdens/patient loads of designated comprehensive hospitals, manage COVID-19 patients centrally, eliminate virus transmission routes, and protect susceptible populations from COVID-19."
Patients who develop severe illness are transferred from the temporary hospitals to comprehensive care hospitals.
The temporary hospitals are 10 times less expensive than building a new comprehensive COVID-19 care hospital, and they reduce fear and anxiety in the community, the journal article says. "These facilities serve to quickly contain all potential sources of infection from the public, and because all patients have the same confirmed COVID-19 virus, patient-to-patient cross infection is not present."
Wuchang Ark Hospital in Wuhan, China, was established in a sports arena. Photo credit: Anesthesiology
5-step process
The Wuhan temporary COVID-19 hospitals utilized five strategies to build and operate the facilities.
1. Infrastructure renovation and infection control: In early February, the journal article's co-authors established a temporary hospital (Wuchang Ark Hospital) in a Wuhan sports arena. The first step was ensuring that the arena could be renovated to comply with international infection control and treatment standards.
"Through close communication with our architects and engineers, we provided constructive advice on patient care area distribution, hallway design, electricity arrangement, and information network connections," the journal article says.
2. Hospital configuration and staffing management: At Wuchang Ark Hospital, the clinical care area including an ICU is in the arena, and supply, screening, and testing facilities are located in tents and ambulances outside the arena. The clinical care staff is drawn from a national emergency team and local medical professionals.
Recent staffing at the temporary hospital featured 125 physicians, 500 nurses, and 90 administrative workers. There are several personnel departments at the hospital, including administration, clinical care, infection control, and supply chain.
3. Procedure and policy standardization: With the temporary hospital's staff drawn from several sources, standard procedures and policies were necessary, including patient identification verification policy, admission and discharge procedures, medical waste disposal procedures, and standards for nursing, infection control, and supply chain.
There also are priorities for patient care, the journal article says. "We especially focus on the elderly and patients with comorbidities secondary to the high mortality rate in this population. Fear, anxiety, and depression are common, and we provide mental health care and intervene on emotionally unstable patients."
4. Staff education and infection control measures: When the temporary hospital opened, infectious disease experts provided infection control and prevention training as well as guidance on how to use personal protective equipment. The infectious disease experts also provided training for three levels of infection control procedures.
Level 1 infection control features scrubbing, disposable hats, disposable gowns, and disposable surgical masks. Level 2 infection control features scrubbing, disposable hats, medical masks—N95 or above, anti-fog eye and face shields, disposable gloves, and disposable shoe covers. Level 3 infection control features all Level 2 requirements, except eye and face shields are replaced with positive pressure respirator hoods.
Training efforts were extensive, the journal article says. "Our Division of Infectious Disease provided 13 sessions to educate more than 500 physicians, nurses, policemen, security, and environmental services. For our team of more than 450 nurses, we provided training with lectures, simulations, and live demonstrations on proper throat swab procedures in COVID-19 patients for testing."
5. Supply preparation and logistics management: "Frontline leadership and the National Health Commission coordinated with local government public health departments to ensure adequate personal protective equipment for healthcare providers as well as daily necessities. Special attention is paid to fulfill the personal needs of patients if possible to help relieve their anxiety," the journal article says.
During the coronavirus pandemic, telemedicine is way for physician practices to offer expanded services and to interact with patients safely.
The American Medical Association (AMA) is providing guidance to physician practices to set up telemedicine services for their patients.
Telemedicine provides physician practices with a safe method to interact with patients remotely during the coronavirus disease 2019 (COVID-19) pandemic. Telemedicine also enables physician practices to expand services for patient care such as virtual patient check-in capabilities and remote patient monitoring that collects biometric data.
An overview document, "AMA quick guide helps doctors boot up the telemedicine practice," includes guidance on changes to federal telemedicine policy and privacy regulations during the COVID-19 pandemic.
"For example, the Centers for Medicare & Medicaid Services (CMS) is letting physicians provide beneficiaries a wider range of healthcare services without having to visit a healthcare facility. This CMS fact sheet explains more. Also, the Health and Human Services (HHS) Inspector General is waiving Medicare's cost-sharing requirements for COVID-19 treatment delivered via telehealth from a doctor's office or hospital emergency department," the overview document says.
In addition to the overview document, the AMA has a quick guide that features tabs for telemedicine practice implementation; policy, coding, and payment; and other helpful resources.
Telemedicine practice implementation
There are three steps to start setting up telemedicine services at a physician practice, the quick guide says:
1. Establish a team to lead the effort to implement telemedicine services and make decisions rapidly to expedite the launch.
2. Contact your malpractice insurance carrier to see whether your policy covers telemedicine services.
3. Learn about telemedicine payment and policy guidelines.
There are four steps for vendor vetting and contracting:
1. See whether your electronic health record vendor has a telemedicine capability that can be implemented.
2. Contact your state medical association to see whether it has guidance for telemedicine vendor vetting and contracting.
3. To implement telemedicine quickly, there are three primary considerations: making sure it is clear who has access to and ownership of data gathered in a patient visit, pricing structure such determining whether there is a monthly flat fee with your telemedicine vendor or a per visit fee, and Health Insurance Portability and Accountability Act compliance.
"Given the special circumstances of the COVID-19 pandemic, the federal government has announced that the Office for Civil Rights (OCR) will exercise its enforcement discretion and will not impose penalties on physicians using telehealth in the event of noncompliance with regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA) in connection with the good faith provision of telehealth during the COVID-19 national public health emergency," the AMA quick guide says.
4. Use American Telemedicine Association resources to identify possible vendors. Some vendors are offering quick implementation of telehealth services.
There are five primary considerations for workflow and patient care:
1. Set protocols for when a telemedicine visit is appropriate, and train clinicians, other healthcare workers, and office staff. Contact your most significant commercial payers to discuss telemedicine reimbursement.
2. Set when telemedicine visits will be conducted such as throughout the day or in a block of time.
3. Establish a space in your practice to conduct telemedicine visits such as an exam room.
4. Document telemedicine visits—ideally in your existing electronic health record. The documentation should include consent from patients to receive telemedicine services.
5. Conduct patient outreach such as alerting patients that telemedicine services are available when they call your office or visit your website.